[Sexual dysfunction associated with psychotropic drugs and treatment options]. / Psychopharmakaassoziierte sexuelle Funktionsstörungen und ihre Behandlung.

BACKGROUND: Sexual dysfunction associated with psychotropic drugs is a threat to patient quality of life and a major reason for non-compliance. Psychotropic agents can impair the sexual response in different ways due to their neurobiological mode of action. OBJECTIVE: Presentation of the frequencies of sexual functional disorders for selected psychopharmacological groups and the available treatment modalities. METHODS: Literature search, selection and review of relevant studies. RESULTS: The most relevant groups for impairments are antidepressants and antipsychotics due to the serotonin agonistic and anti-dopaminergic properties as well as the prolactin increasing characteristics. Agents with a favorable side effects profile are now available. All phases of the sexual response are affected. DISCUSSION: The treatment of psychiatric disorders should follow a comprehensive treatment plan that anticipates a likely sexual dysfunction at the initiation of treatment. The main aim is improvement of the underlying primary disorder. Some limited evidence-based treatment strategies are available.

[Addiction counselling in the surgical emergency room. Implementation of a brief intervention for alcohol-intoxicated patients]. / Suchtberatung in der unfallchirurgischen Notaufnahme. Implementierung einer Kurzintervention bei alkoholintoxikierten Patienten.

INTRODUCTION: The primary care system, especially emergency rooms, seems to be an ideal location for the implementation of brief interventions for secondary prevention of alcohol use disorders. The present study examines whether a brief intervention can both lead to a reduction in alcohol quantity and consumption frequency as well as to an increased contact with alcohol counselling services. METHODS: The brief intervention for patients with alcohol consumption consisted of an interview about the alcohol drinking patterns and the delivery of a flyer from the local counselling services. One month later a follow-up interview was conducted. RESULTS: A total of 64 patients participated in the study; 37 patients gave their consent for follow-up. Patients with harmful/dependent alcohol use significantly reduced their alcohol amount (p<0,001) and consumption frequency (p<0,02). Patients who linked the injury to the consumed alcohol reduced their drinking frequency significantly more than those who did not (p=0,01). The intervention had no influence on the contact rate with counselling services. DISCUSSION: Promising evidence was found, which needs confirmation in the form of randomized controlled trials with focus on long-term effects.

Involvement of the atrial natriuretic peptide transcription factor GATA4 in alcohol dependence, relapse risk and treatment response to acamprosate.

In alcoholism, both relapse to alcohol drinking and treatment response are suggested to be genetically modulated. This study set out to determine whether the top 15 single nucleotide polymorphisms (SNPs) of a recent genome-wide association (GWA) and follow-up study of alcohol dependence are associated with relapse behavior and pharmacological treatment response in 374 alcohol-dependent subjects who underwent a randomized, double-blind, placebo-controlled trial with acamprosate, naltrexone or placebo. The single nucleotide polymorphism, rs13273672, an intronic SNP in the gene for GATA-binding protein 4 (GATA4), was associated with relapse within the 90-day medical treatment period (P<0.01). Subsequent pharmacogenetic analyses showed that this association was mainly based on patients treated with acamprosate (P<0.01). In line with the observation that natriuretic peptide promoters are modulated by GATA4, a significant gene dose effect on the variance of atrial natriuretic peptide (ANP) plasma concentration in the different GATA4 genotypes (P<0.01) was found. Hence, genetic variations in GATA4 might influence relapse and treatment response to acamprosate in alcohol-dependent patients via modulation of ANP plasma levels. These results could help to identify those alcohol-dependent patients who may be at an increased risk of relapse and who may better respond to treatment with acamprosate.

Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders.

AIMS: This project investigated different dissemination strategies of an online quality improvement programme for alcohol-related disorders into routine care in South Baden and South Württemberg in Germany. METHODS: In a cluster-randomized controlled trial, 112 general practices were randomized into three groups. The first group (n = 43) received access to the online system and a training programme for the general practitioners (GPs). The second group (n = 42) additionally received education for the whole practice team. The third group (n = 27) acted as control and received only access to the online system. RESULTS: Two thousand six hundred and forty-seven practitioners were asked to take part in the study, and it was possible to randomize 112 (4%) practices. There were no significant differences concerning the use of the system between the groups: 41.9% of the GPs in the first group, 42.9% in the second group and 44.4% in the control group used the system. In terms of only the system users, 55.6% of the GPs in the first group, 33.3% in the second group and 8.3% in the control group used the system six times or more (P = 0.019). Diagnostic assessments made by the GPs in the groups differed substantially: 72.2% of diagnoses in the first group were correct, while this figure lay at 69.7% in the second group and 36.4% in the control group (P = 0.034). CONCLUSIONS: No effect of the additional training on the primary outcome (acceptance) was identified, but on two of the secondary outcomes. Further cost-effectiveness studies should investigate whether the effort involved in providing training additionally to the system is justifiable. The study is registered at ClinicalTrials.gov: NCT00314067. This article conforms to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al., 2001; Campbell et al., 2004).

[Sexual dysfunction and its consequences in patients with cardiovascular diseases]. / Sexuelle Funktionsstörungen bei Herzkranken und die Folgen.

PURPOSE: Due to the high prevalence of sexual disorders in men and women with cardiovascular disease, the associations between sexual dysfunction, depression, anxiety, quality of life and partnership were investigated. Studies examining impairments to certain aspects of psychological health and interpersonal life in cardiac patients are still lacking. The SPARK (Sexuality of Patients in Rehabilitation of Cardiovascular Diseases) investigation is the first study which explores these relevant associations in German rehabilitation patients. METHODS: Five rehabilitation centers for cardiovascular diseases took part in our cross-sectional study. Associations between sexual dysfunction and depression, anxiety, quality of life and partnership were tested using z-tests (resulting parameter prevalence rate ratio, PRR) and via multiple binary logistic regressions controlling for age and severity of cardiovascular disease as possible confounders (resulting parameter odds ratio, OR). RESULTS: Sexual function could be assessed in 261 men and 75 women (sexual activity during the previous month; for detailed flow chart see Fig. 1). In total, 43.1% of female patients reported a sexual dysfunction, while 20.2% of male patients stated to have at least moderate erectile dysfunction (ED). The proportion of self-assessed sexual problems is shown in Fig. 2. Women with a sexual dysfunction were impaired to a significantly higher extent compared to women without sexual dysfunction with regard to their quality of partnership (PRR 13.0; p=0.019; OR 25.42, confidence interval, CI, 2.5-254.9), anxiety (PRR 3.2; p=0.053; OR 4.43, CI 1.2-16.4) and psychological quality of life (PRR 2.4; p=0.115; OR 6.08, CI 1.6-22.9). Men with ED reported significantly stronger depression (PRR 3.6; p=0.003; OR 3.63, CI 1.5-8.8) and anxiety (PRR 2.4; p=0.008; OR 2.88, CI 1.4-5.9) compared to men without ED. For detailed information see Tables 1 and 2. CONCLUSION: Due to the high proportion of men and women with cardiovascular disease reporting sexual disorders, depression and anxiety, screening for these disorders should be an integral part of comprehensive rehabilitation programs. In particular, the diagnosis and treatment of psychiatric comorbidity seem to be necessary from a tertiary preventive perspective.

Finding the ideal place for a psychotherapeutic intervention in a stepped care approach--a brief overview of the literature and preliminary results from the Project PREDICT.

AIMS: To provide an overview over empirical evidence regarding stepped care approaches that include psychotherapies. To present own preliminary study results in alcohol dependent patients. METHODS: Publications were searched in the databases Medline, PsycINFO and the internet search engine Google Scholar. Inclusion criteria were psychosocial treatment and psychiatric disorders. Our own study consists of two steps. In step 1 patients receive anti-craving medication or placebo and Medical Management (MM). After a relapse to heavy drinking patients can step up and after randomization they either continue with the same treatment or they receive additional alcoholism specific psychotherapy (ASP). RESULTS: Evidence suggests that stepped care might be efficacious in patients with obsessive-compulsive behavior and depression. There is no evidence for efficacy in problem drinkers. Results of our own study show that the completer rate in MM alone is higher than in ASP with MM, but there are no significant differences concerning age, sex and disease severity between completer and non-completer in both study arms. CONCLUSIONS: Further research with regard to stepped care in alcohol dependent patients is needed. An introduction of the psychotherapy at earlier stages might be sensible.

A typology of men's sexual attitudes, erectile dysfunction treatment expectations and barriers.

In total, 1122 men completed non-validated structured interviews on sexual attitudes and on erectile dysfunction treatment expectations and barriers. Dimensions of sexual attitudes and treatment expectations and barriers were extracted by factor analysis and subjects were grouped into types by cluster analysis. Five types emerged: the sensation seeker, the sensuous, the anxious, the confident and the abstinent. The majority of men agreed on the importance of sex for the partnership. For the majority of anxious, sensuous and sensation-seeking men, sex was important for self-esteem. Expecting quality of life, enjoyment, self-esteem and hard reliable erections from treatment with phosphodiesterase-5 inhibitors, anxieties for side effects and loss of control, sexual abstinence and desire for an intensive sex life had the strongest impact on the likelihood of use. Men's sexual attitudes vary considerably and impact reactions to erection difficulties. A typology of five groups was developed, which will contribute to research on and understanding of men's sexual and treatment-seeking behaviors.

Can written information material help to increase treatment motivation in patients with erectile dysfunction? A survey of 1188 men.

Although erectile dysfunction (ED) prevalence is high, patients and physicians often have problems discussing this issue. This study examines whether written information material increases motivation to seek treatment in patients with ED. For the study, persons were able to order information material about sexual problems within the context of a public campaign. From a total of 70,000 responders, 8000 persons were asked to fill out an epidemiological questionnaire. The response rate yielded 18.4%, the data of 1188 men with ED were analyzed. As a result of the information material, 28.3% of the untreated men intended to seek treatment and 38.5% of the men who had not spoken with their physician about their problem, planned to do so now. Nearly all responders were satisfied with the information material. These data reflect the usefulness of written information for men with ED. It not only serves as an informational source for patients but may also encourage them to seek treatment.

Management of sexual dysfunction due to antipsychotic drug therapy.

BACKGROUND: Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, sexual arousal or overall sexual satisfaction. OBJECTIVES: To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (June 2006), the Cochrane Library (Issue 2, 2005), MEDLINE (1966-8/2005), PsycLIT (1974-8/2005), EMBASE (1980-8/2005) and references of all identified studies for further trials. We contacted relevant pharmaceutical companies and authors of trials. SELECTION CRITERIA: We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction. DATA COLLECTION AND ANALYSIS: Working independently, we extracted data. For dichotomous data we calculated random effects odds ratios (OR) with 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data we calculated weighted mean differences on the basis of a random effects model. We analysed crossover trials under consideration of correlation of paired measures. MAIN RESULTS: Currently this review includes two pioneering crossover studies (total n=42 men, duration 2-3 weeks). They reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n=32, WMD 3.20 CI 1.83 to 4.57), a greater mean duration of erections (n=32, WMD 1.18 CI 0.52 to 1.84) and frequency of satisfactory intercourse (n=32, WMD 2.84 CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n=10, WMD change on Aizenberg's sexual functioning scale -0.40 CI -3.95 to 3.15). AUTHORS' CONCLUSIONS: We are not confident that crossover studies are appropriate for this participant group. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Further well designed, conducted and reported trials are urgently needed.

Vein Patch Closure Using Below the Knee Greater Saphenous Vein for Femoral Endarterectomy Procedures is Not Always a Safe Choice.

BACKGROUND: The complication of vein patch rupture is well described after carotid patch angioplasty; however, there is a paucity of data about the safety of vein patch closure in the setting of femoral endarterectomy. METHODS/RESULTS: From May 2012 to May 2015, 115 femoral endarterectomies with patch closure were performed. A patch rupture occurred in three cases (2.6%) with a mortality rate of 66% (2/3). In all cases the greater saphenous vein below the knee was used as patch material. DISCUSSION/CONCLUSION: Vein patches, particularly from small calibre veins, should be excluded in femoral endarterectomy procedures as they pose a substantial risk of rupture.

Efficacy of PDE-5-inhibitors for erectile dysfunction. A comparative meta-analysis of fixed-dose regimen randomized controlled trials administering the International Index of Erectile Function in broad-spectrum populations.

This meta-analytic study aims to estimate the likely improvements of erectile dysfunction (ED) measured by the International Index of Erectile Function (IIEF) at the highest fixed dosages of the three available PDE-5-inhibitors: sildenafil, tadalafil, and vardenafil. MEDLINE and the Cochrane Library were searched electronically for efficacy trials of PDE-5-inhibitors for treating ED. In addition drug manufacturers were contacted to provide unpublished or unrecorded congress proceedings. Randomized, double-blind, placebo-controlled, parallel-group, maximum fixed-dose, broad-spectrum efficacy trials using IIEF were included in the analysis. Data were independently extracted by two reviewers. The results were pooled using weighted mean differences. A formal indirect comparison (including Bonferroni-correction) was conducted to estimate the differences between agents. A total of 14 trials were included in the meta-analysis (three with 100 mg sildenafil, eight with 20-25 mg tadalafil, and three with 20 mg vardenafil). All trials were of good methodological quality. Overall heterogeneity was moderate: I(2)=33.2%, chi(2)=19.47, P=0.11. The funnel plot suggested moderate likelihood of publication bias. Pooled results of IIEF-improvement were for sildenafil 9.65 (95% CI: 8.50, 10.79) points, tadalafil 8.52 (7.61, 9.42) points, and vardenafil 7.50 (6.50, 8.50) points, respectively. Sildenafil proved to be significantly more effective than vardenafil (d=2.15, P=0.006), other pairwise comparisons showed no difference in efficacy. All PDE-5-inhibitors are highly effective in the treatment of ED. At maximum dosage they improve erectile function 7-10 points on the IIEF compared to placebo-treatment. There is evidence that sildenafil might be more efficacious than vardenafil, although this is to be interpreted with caution. To prove higher efficacy truly independent comparative trials are needed.

A meta-regression analysis of treatment effect modifiers in trials with flexible-dose oral sildenafil for erectile dysfunction in broad-spectrum populations.

Several trials and reviews provide evidence for the efficacy of phosphodiesterase-5 inhibitors in the treatment of erectile dysfunction (ED). However, little is known about the impact of treatment effect modifiers other than concomitant diseases. Our objective was to identify patient and trial characteristics as well as methodological and publication-related issues that are associated with the treatment effect measured in flexible-dose randomized controlled trials of oral sildenafil for ED. The MEDLINE and the Cochrane Central databases were searched for efficacy trials of sildenafil. Thirteen trials fulfilled all inclusion criteria. A series of meta-regression and graphical analyses were performed to test the impact of possible effect modifiers. Treatment effect was influenced by mean baseline disease severity and mean duration of the disease. These associations were at least partly mediated by placebo response. Trial duration, age of patients and etiology of ED in patients did not have any significant influence on the treatment effect. The year of publication of primary trials was also related to trial findings. Our analysis adds important data to enable the control of confounding variables in future trials and meta-analyses. It might also help the individual to assess the unbiased efficacy and true innovative potential of available and forthcoming pharmacological agents.

Inhaled nitric oxide versus aerosolized iloprost in secondary pulmonary hypertension in children with congenital heart disease: vasodilator capacity and cellular mechanisms.

BACKGROUND: Inhaled nitric oxide (iNO) has been used to assess the vasodilator capacity of the pulmonary vascular bed in children with congenital heart disease and elevated pulmonary vascular resistance. Inhaled iloprost is a pulmonary vasodilator for the long-term treatment of pulmonary hypertension (PHT). Because these 2 vasodilators act through different pathways (release of cGMP or cAMP, respectively), we compared the pulmonary vasodilator capacity of each. METHODS AND RESULTS: A total of 15 children with congenital heart disease and PHT who had elevated pulmonary vascular resistance (preoperative, n=10; immediately postoperative, n=5) were first given 20 ppm of iNO for 10 minutes; then, after baseline values were reached again, they were given aerosolized iloprost at 25 ng. kg(-1). min(-1) for another 10 minutes. Finally, iNO and iloprost were given simultaneously for 10 minutes. With iNO, the pulmonary vascular resistance and systemic vascular resistance ratio decreased from 0.48+/-0.38 to 0.27+/-0.16 (P:<0.001). Similarly, iloprost decreased the ratio from 0.49+/-0.38 to 0.26+/-0.11 (P:<0.05). The combination had no additional effect on the resistance ratio. Plasma cGMP increased from 17.6+/-11.9 to 34.7+/-21.4 nmol/L during iNO (P:<0.01), and plasma cAMP increased from 55.7+/-22.9 to 65.1+/-21.2 nmol/L during iloprost inhalation (P:<0.05). CONCLUSIONS: In children with PHT and congenital heart disease, both iNO and aerosolized iloprost are equally effective in selectively lowering pulmonary vascular resistance through an increase in cGMP or cAMP, respectively. However, the combination of both vasodilators failed to prove more potent than either substance alone. Aerosolized iloprost might be an alternative to iNO for early testing of vascular reactivity and for the postoperative treatment of acute PHT.

St John's wort for depression.

BACKGROUND: Extracts of the plant Hypericum perforatum L. (popularly called St. John's wort) have been used in folk medicine for a long time for a range of indications including depressive disorders. OBJECTIVES: To investigate whether extracts of hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of depressive disorders in adults; and whether they have have less adverse effects than standard antidepressant drugs. SEARCH STRATEGY: Trials were searched in computerized databases (Cochrane Collaboration Depression, Anxiety & Neurosis Group Clinical Trials Registers; PubMed); by checking bibliographies of pertinent articles; and by contacting manufacturers and researchers. SELECTION CRITERIA: Trials were included if they: (1) were randomized and double-blind; (2) included patients with depressive disorders; (3) compared extracts of St. John's wort with placebo or standard antidepressants; and (4) included clinical outcomes such as scales assessing depressive symptoms. DATA COLLECTION AND ANALYSIS: Information on patients, interventions, outcomes and results was extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of hypericum with placebo and standard antidepressants was the responder rate ratio (responder rate in treatment group/responder rate in control group). The main outcome measure for adverse effects was the number of patients dropping out for adverse effects. MAIN RESULTS: A total of 37 trials, including 26 comparisons with placebo and 14 comparisons with synthetic standard antidepressants, met the inclusion criteria. Results of placebo-controlled trials showed marked heterogeneity. In trials restricted to patients with major depression, the combined response rate ratio (RR) for hypericum extracts compared with placebo from six larger trials was 1.15 (95% confidence interval (CI), 1.02-1.29) and from six smaller trials was 2.06 (95% CI, 1.65 to 2.59). In trials not restricted to patients with major depression, the RR from six larger trials was 1.71 (95% CI, 1.40-2.09) and from five smaller trials was 6.13 (95% CI, 3.63 to 10.38). Trials comparing hypericum extracts and standard antidepressants were statistically homogeneous. Compared with selective serotonin reuptake inhibitors (SSRIs) and tri- or tetracyclic antidepressants, respectively, RRs were 0.98 (95% CI, 0.85-1.12; six trials) and 1.03 (95% CI, 0.93-1.14; seven trials). Patients given hypericum extracts dropped out of trials due to adverse effects less frequently than those given older antidepressants (Odds ratio (OR) 0.25; 95% CI, 0.14-0.45); such comparisons were in the same direction, but not statistically significantly different, between hypericum extracts and SSRIs (OR 0.60, 95% CI, 0.31-1.15). AUTHORS' CONCLUSIONS: Current evidence regarding hypericum extracts is inconsistent and confusing. In patients who meet criteria for major depression, several recent placebo-controlled trials suggest that the tested hypericum extracts have minimal beneficial effects while other trials suggest that hypericum and standard antidepressants have similar beneficial effects. As the preparations available on the market might vary considerably in their pharmaceutical quality, the results of this review apply only to the products tested in the included studies.

Treatment expectations of men with ED and their female partners: an exploratory qualitative study based on grounded theory.

Erectile dysfunction (ED) can impair the quality of life and the relationship. An early treatment is necessary to avoid the development of comorbid complaints. To arise the help-seeking behavior and to improve the treatment of affected men, it is necessary to be aware of the treatment expectations. The objective of this study was to investigate the treatment expectations of men with ED and their female partners. This is an explorative qualitative study using semistructured telephone interviews with 12 men with ED and their female partners. Interviews were tape-recorded, transcribed and analyzed on the basis of the grounded theory. We could identify various treatment expectations, which could be differentiated into expectations according to the conditions (for example, low costs and an early access), the handling of the practitioner (for example, showing interest and taking the patient seriously or incorporate the female partner), the treatment itself (for example, clearing the causes and helpful medication) and the treatment outcome (for example, having no ED and more sexual desire). Considering the identified expectations could increase treatment motivation and compliance. We derive five theses from our data, how to implement our findings.

Monosegmental liver transplantation from an adult to an infant.

A shortage of small pediatric organ donors has led to the development of reduced size liver transplantation in children. However, the discrepancy between donor and recipient weight can limit the use of this procedure despite transplantation of the left lobe only. Monosegmental liver transplantation using segment III only was recently described. We report here the case of an 11 month old, 6.9 kg boy who received another monosegmental graft (segment II) from a 78 kg donor on an urgent basis. Because of the lack of parenchymal landmarks between segments II and III, sterile methylene blue solution was injected into the portal vein of segment III: parenchyma of this segment colored immediately and was resected accordingly. Three and a half years later, the growth, development, and nutrition of this child were normal. This procedure seems to be helpful when the left lobe of the graft is obviously too large.

Inhaled nitric oxide to test the vasodilator capacity of the pulmonary vascular bed in children with long-standing pulmonary hypertension and congenital heart disease.

Nitric oxide-induced vasodilator capacity greatly varies among children with pulmonary hypertension and elevated vascular resistance. The decline of this selective response seems to parallel the progression of established vascular disease and thus may be helpful for the selection of patients for operation.

Chronotropic and inotropic supports are both required to increase cardiac output early after corrective operations for tetralogy of Fallot.

To assess the respective roles of chonotropism, inotropism, and afterload reduction in increasing cardiac index early after corrective operations for tetralogy of Fallot, we measured vascular pressures and cardiac output and evaluated left ventricular dimension changes before and after a 35% rise in heart rate over baseline. This rise was induced by atrial pacing with intact atrioventricular conduction, isoproterenol, or atrial pacing together with dobutamine. With atrial pacing, left ventricular end-diastolic diameter decreased (38.7 +/- 4.3 to 34.2 +/- 5.6 mm, p less than 0.05), the shortening fraction (ratio of the difference between left ventricular end-diastolic and end-systolic diameters to left ventricular end-diastolic diameter) remained constant, and stroke volume index was reduced (28.8 +/- 4.5 to 19.7 +/- 4.6 ml/m2, p less than 0.05). As a result, cardiac index was left unchanged. When dobutamine was added as supplemental inotropic support, left ventricular end-diastolic diameter remained constant, shortening fraction increased (30% +/- 5.4% to 36% +/- 3.3%, p less than 0.05), and cardiac index rose significantly (3.04 +/- 0.61 to 4.18 +/- 0.85 L/min/m2, p less than 0.05). Heart rate acceleration with isoproterenol, combining chronotropism, positive inotropic support, and afterload reduction, slightly increased left ventricular end-diastolic diameter, significantly raised shortening fraction, and markedly enhanced cardiac index (3.03 +/- 0.55 to 4.9 +/- 1.09 L/min/m2). Atrial pacing with intact atrioventricular conduction, as an isolated chronotropic stimulus, is not suited to increase cardiac index early after operations for tetralogy of Fallot unless additional inotropic support is simultaneously provided.

Hemodynamic effect of isoprenaline and dobutamine immediately after correction of tetralogy of Fallot. Relative importance of inotropic and chronotropic action in supporting cardiac output.

In order to compare the effect of isoprenaline and dobutamine immediately after correction of tetralogy of Fallot, 12 randomly selected patients were studied postoperatively. Left ventricular end-diastolic volume, measured preoperatively by means of left ventricular angiograms in eight patients, was decreased to a mean value of 58.6 +/- 5.5 ml/m2 (mean +/- standard error of the mean). Postoperatively, cardiac output was measured by thermodilution before, during, and after infusion of increasing doses of isoprenaline (0.05, 0.1, and 0.2 micrograms/kg/min) and dobutamine (2.5, 5, and 10 micrograms/kg/min) successively given in each patient. Simultaneously, central venous, left atrial, pulmonary arterial, and systemic arterial pressures were recorded. Cardiac index increased significantly in response to all three doses of isoprenaline. Dobutamine produced only a small increase which was not statistically significant. Stroke volume index did not vary significantly with either drug. Consequently, cardiac index was directly related to heart rate. Preload of the left ventricle as well as afterload was significantly reduced (p less than 0.01 and p less than 0.05, respectively) by isoprenaline but not by dobutamine. An increase in left ventricular work index per minute was found with both drugs; however, only with isoprenaline was the increased work accompanied by a significant increase in cardiac index. We conclude that patients with tetralogy of Fallot usually have a small left ventricle which, immediately after correction, reacts to catecholamines by only an insignificant increase in stroke volume index. Consequently, isoprenaline is more effective than dobutamine in raising cardiac index due to the increase in heart rate. Moreover, it decreases systemic vascular resistances and obviates the need for administration of a vasodilator.

Use of Gianturco Z stents in the treatment of vascular compression of the tracheobronchial tree in childhood. A feasible solution when surgery fails.

Severe tracheomalacia secondary to extrinsic vascular compression following a switch operation for transposition is reported. Two attempts at surgical correction failed but successful treatment has been achieved by implantation of two endobronchial Gianturco Z stents. Nonabsorbable stenting in children should be used only in severe obstruction as a last resource, but this technique proved to be feasible in a child weighing 6.2 kg.